9 CSR 45-7.010 - Developmental Disabilities Health Home
PUBLISHER'S NOTE: The secretary of state has determined that publication of the entire text of the material that is incorporated by reference as a portion of this rule would be unduly cumbersome or expensive. This material as incorporated by reference in this rule shall be maintained by the agency at its headquarters and shall be made available to the public for inspection and copying at no more than the actual cost of reproduction. This note applies only to the reference material. The entire text of the rule is printed here.
(1) Definitions.
(A) Behavioral Health-The promotion of mental
health, resilience, and well-being, the treatment of mental health and
substance use disorders, and the support of individuals who experience and/or
are in recovery from these conditions, along with their family or other natural
supports and communities.
(B)
Centers for Medicare & Medicaid Services (CMS)-CMS is a federal agency
within the United States Department of Health and Human Services that
administers Medicaid programs.
(C)
Chronic or At-Risk Conditions-For the purpose of DD Health Home eligibility,
chronic or at-risk conditions are as follows:
1. Intellectual and/or developmental
disability;
2. Diabetes;
3. Asthma;
4. Cardiovascular disease (CVD) or
hypertension;
5. Chronic
obstructive pulmonary disease (COPD);
6. Overweight (body mass index
(BMI)>25);
7.
Dementia;
8. Dependent on a
ventilator;
9. One (1) of the Fatal
Five Plus conditions or one (1) or more chronic conditions that could lead to
one (1) of the following Fatal Five Plus conditions:
A. Pulmonary aspiration;
B. Bowel obstruction;
C. Gastroesophageal reflux disease
(GERD);
D. Seizures;
E. Sepsis;
F. Dehydration;
10. Tobacco use;
11. Diagnosis of Autism Spectrum Disorder;
and
12. Healthcare level of 3 or
greater as identified by the Health Risk Screening Tool.
(D) EMR-Electronic medical records, also
referred to as electronic health records (EHR).
(E) Health Home-A Health Home provides
coordination of health care to individuals with chronic physical and/or
behavioral health conditions, using a partnership or team approach between the
Health Home team and individuals in order to achieve improved health care, to
avoid preventable hospitalizations and emergency department use.
(F) DD Health Home Enrollees-Individuals
eligible for Division of DD services with one (1) or more chronic/at-risk
conditions as defined in enrollment/eligibility criteria section.
(G) DD Health Home Provider-DD Contracted
Targeted Case Management (TCM) and/or DD Home and Community-Based Services
(HCBS) certified or accredited waiver providers who meet criteria for DD health
home provider eligibility.
(H) DD
Health Home Team-DD Health Home core team shall consist of the following staff:
Health Home Director, Nurse Care Manager, Physician Consultant (Advanced
Practice Registered Nurse (APRN) as substitute and defined in the DD
Health Home Provider Operations Manual), Specialized Healthcare
Consultant, and DD Health Home Facilitator. Based on the unique needs of the
individual, additional staff may be identified.
(I) Health Risk Screening Tool-The Health
Risk Screening Tool (HRST) is a tool used to provide early detection of health
risks and destabilization.
(J)
Health Risk Support Plan (HRSP)-The HRSP are standardized electronic templates
in the department's identified system which is a component of the individual's
Individual Support Plan (ISP) and serves to identify implementation strategies
to mitigate risk and improve health outcomes.
(K) Intellectual and/or Developmental
Disability (IDD)- Adults and youth who meet the Missouri state statute
definition of Developmental Disability, section
630.005(9),
RSMo. "Developmental disability," a disability that is attributable to
intellectual disability, cerebral palsy, epilepsy, head injury or autism, or a
learning disability related to a brain dysfunction; or any other mental or
physical impairment or combination of mental or physical impairments; and is
manifested before the individual attains age twenty-two (22); and is likely to
continue indefinitely; and results in substantial functional limitations in two
(2) or more of the following areas of major life activities: self-care;
receptive and expressive language development and use; learning;
self-direction; capacity for independent living or economic self-sufficiency;
mobility; and reflects the individual's need for a combination and sequence of
special, interdisciplinary, or generic care, habilitation or other services
which may be of lifelong or extended duration and are individually planned and
coordinated.
(L) Missouri
Department of Social Services (DSS), MO HealthNet Division (MHD)-Single State
Medicaid authority.
(M) Social
Determinants of Health (SDOH)-The nonmedical factors that influence health
outcomes. They are the conditions in which people are born, grow, work, live,
and age, and the wider set of forces and systems shaping the conditions of
daily life. These forces and systems include economic policies and systems,
development agendas, social norms, social policies, racism, climate change, and
political systems.
(2)
Developmental Disabilities Health Home Qualifications.
(A) Initial Provider Qualifications. In
addition to being a DD service provider of TCM or DD HCBS waiver services, each
DD Health Home provider must meet state qualifications, which may be amended
from time to time as necessary and appropriate, but minimally require that each
Health Home-
1. Must be enrolled in
Missouri's Medicaid program and agree to comply with all Medicaid program
requirements;
2. DD Health Home
providers can either directly provide, or subcontract for the provision of DD
Health Home services. The DD Health Home remains responsible for all DD Health
Home program requirements, including services performed by the
contractor;
3. Have strong, engaged
leadership personally committed to and capable of leading the DD Health Home
through the transformation process and sustaining transformed DD Health Home
processes as demonstrated through-
A. The
provider designation review;
B.
Agreement to participate in learning activities, including in-person sessions
and regularly scheduled phone calls; and
C. Provider leadership, in collaboration with
the state, have presented the state-developed introductory presentation to
Missouri's DD Health Home initiative to provider staff and board of
directors;
4. Meet the
state's minimum access requirements as follows: Prior to implementation of DD
Health Home service coverage, provide assurance of enhanced individual access
to the health team, including the development of alternatives to face-to-face
visits, such as telephone or email, twenty-four (24) hours per day seven (7)
days per week;
5. Actively use MHD
and DMH information technology (IT) systems to conduct care coordination and
prescription monitoring for Medicaid individuals;
6. Utilize the department's identified system
to input annual metabolic screening results, track and measure care of
individuals, automate care reminders, and maintain other items as required by
the department;
7. Routinely use an
electronic health management tool to determine individualized health risks
(i.e., Health Risk Screening Tool (HRST));
8. Routinely use an electronic health
management tool to determine problematic prescribing patterns;
9. Conduct wellness interventions as
indicated based on the individual's level of risk;
10. Agree to convene regular, ongoing, and
documented internal DD Health Home team meetings to plan and implement DD
Health Home healthcare goals and objectives of ongoing practice
transformation;
11. Agree to
participate in CMS and state-required evaluation activities;
12. Agree to develop required reports
describing DD Health Home activities, efforts, and progress in implementing DD
Health Home services;
13. Maintain
compliance with the terms and conditions as a DD Health Home provider or risk
termination as a provider of DD Health Home services;
14. Present a proposed DD Health Home service
delivery model the department determines will have a reasonable likelihood of
being cost-effective. Cost effectiveness will be determined based on the size
of the proposed DD Health Home, Medicaid caseload, percentage of caseload with
eligible chronic conditions of individuals, and other factors to be determined
by DMH.
(B) Ongoing
Provider Qualifications. Each provider must also-
1. Continue to have a strong, engaged
leadership personally committed to and capable of leading the DD Health Home
through the transformation process and sustaining transformed DD Health Home
processes as evidenced by successful participation in the leadership training
and learning collaborative developed for DD Health Home;
2. Coordinate care and build relationships
with regional hospital(s) or hospital system(s) to develop a structure for
transitional care planning, including communication of inpatient admissions of
DD Health Home individuals, and maintain a mutual awareness and collaboration
to identify individuals seeking emergency department services who might benefit
from connection with a DD Health Home, and encourage hospital staff to notify
the area DD Health Home staff of such opportunities;
3. Develop quality improvement plans to
address gaps and opportunities for improvement identified during and after the
application process;
4. Demonstrate
development of fundamental DD Health Home functionality through an assessment
process to be applied by Division of DD;
5. Demonstrate significant improvement on
clinical indicators specified by and reported to Division of DD;
6. Submit data reports as required by DSS
and/or Division of DD;
7. Provide
DD Health Home services that demonstrate overall cost effectiveness;
8. Participate in technical assistance
conference calls and webinars as requested by DSS and/or Division of
DD;
9. Meet standards as determined
by DMH.
(3)
Scope of Services. This section describes the activities Division of DD
providers will be required to engage in, and the responsibilities they will
fulfill, if recognized as a DD Health Home.
(A) Division of DD Health Home Services. The
DD Health Home Team shall assure the following health services are received, as
necessary, by all individuals served in the DD Health Home:
1. Comprehensive care management.
Comprehensive care management services include-
A. Determining level of participation in care
management services based upon individualized information provided through the
HRST and HRSP, and other individual information;
B. Assessment of preliminary service needs,
which includes reviewing and identifying gaps in the overall person-centered
plan which may include the HRSP and Behavior Support Plan (BSP);
C. DD Health Home development of individual
DD Health Home healthcare goals, preferences, and optimal clinical
outcomes;
D. Assigning health team
roles and responsibilities;
E.
Developing guidelines for health teams to follow across risk levels or health
conditions;
F. Monitoring of
individual and population health status and service use to determine adherence
to or variance from DD Health Home healthcare goals and identified service
needs identified in the overall person-centered plan; and
G. Developing and disseminating reports that
indicate the individual's progress toward meeting outcomes for individual
satisfaction, health status, service delivery, and costs;
2. Care coordination. Care coordination is
the implementation of the overall individual person-centered plan with active
individual and family involvement through appropriate linkages, referrals,
coordination, and follow-up to needed services and supports. Care coordination
is designed to be delivered in a flexible manner best suited to the
individual's preferences and to support DD Health Home healthcare goals that
have been identified by developing linkages and skills in order to allow the
individual to reach their full potential and increase their independence in
obtaining and accessing services. Specific activities include but are not
limited to-
A. Participating in hospital
discharge processes to support the individual's transition to the
community;
B. Communicating and
consulting with the individual, providers, and collateral contacts;
and
C. Facilitating regularly
scheduled interdisciplinary team meetings to review person-centered plans and
assess progress toward identified DD Health Home healthcare goals;
3. Health promotion. Health
promotion shall minimally consist of educating and engaging the individual in
making decisions that promote independent living skills and lifestyle choices
that achieve the following goals:
A. Good
health;
B. Proactively managing
chronic conditions;
C. Identifying
risk factors early; and
D.
Screening for emerging health problems;
4. Health promotion services include but are
not limited to-
A. Promoting the individual's
education of their chronic conditions;
B. Developing self-management plans with the
individual;
C. Conducting
medication reviews and regimen compliance;
D. Providing support to the individual for
improving social networks and health-promoting lifestyle interventions,
including but not limited to preventative health practices for the IDD
population, nutritional counseling, obesity reduction and prevention, and
increasing physical activity; and
E. Assisting the individual to participate in
DD Health Home healthcare goal planning with an emphasis on person-centered
empowerment and the development of health literacy skills to help the
individual understand and self-manage chronic health conditions;
5. Comprehensive transitional care
from inpatient to other settings. Comprehensive transitional care services
include but are not limited to-
A.
Facilitating the individual's transition between care levels, such as a
hospital, nursing facility and residential supports, or when opting for a new
DD Health Home provider;
B.
Collaborating and establishing relationships with the individual's physicians,
nurses, social workers, discharge planners, pharmacists, and others to continue
implementation of the overall person-centered plan. Specific focus is on
increasing the individual's ability to manage care and live safely in the
community, and shift the use of reactive care and treatment to proactive health
promotion and self-management;
C.
Communicating with and educating the individual and providers located at the
setting from which the individual is transitioning, and at the setting to which
the individual is transitioning;
D.
Ensuring the individual's prompt access to follow-up care after discharge
(e.g., care record from discharge entity, medication reconciliation, reviewing
person-centered plan to assure access to needed community services, appointment
scheduling); and
E. Providing care
coordination services designed to streamline person-centered plans, reduce
hospital admissions, ease the transition to long-term services and supports,
and interrupt patterns of frequent hospital emergency department use;
6. Individual and family support.
Individual and family support is intended to assist the individual to
facilitate and maintain quality of life and explore community options to
promote overall quality of life through health stabilization and improved
health outcomes. Activities include but are not limited to-
A. Educating and guiding in self-advocacy
support with the individual;
B.
Increasing the individual's health literacy skills and ability to self-manage
their care;
C. Identifying
resources for the individual to address the gaps identified in the overall
person-centered plan to improve his or her overall health and ability to
function within his or her family and in the community;
D. Educating the individual on the importance
of obtaining and adhering to medications and other prescribed treatments;
and
E. Assisting the individual
with developmental disabilities for whom primary services needs are more
directly related to treatment (e.g., treatment for a behavioral health
condition and/or particular healthcare condition(s)), referring and
coordinating with the approved care management entity for the MO Community
Mental Health Center (CMHC) Health Care Home or MO Primary Care Health Home for
services more directly related to those aforementioned conditions;
and
7. Referral to
community and social support services. Referral to community and social support
services involves identifying gaps in the overall person-centered plan that are
connecting the individual to community based resources and referrals that
support Social Determinants of Health (SDOH). It also includes identifying
resources to reduce barriers that will promote the individual's overall quality
of life through health stabilization and improved overall health
outcomes.
(B) DD Health
Home Administration. Each DD Health Home provider shall employ a DD Health Home
Director. The DD Health Home core team shall consist of the following staff:
Nurse Care Manager, Physician Consultant (APRN as a substitute and defined in
the DD Health Home Provider Operations Manual), Specialized
Healthcare Consultant, and DD Health Home Facilitator. Based on the unique
needs of the individual, additional staff may be identified.
(C) Learning Activities. The MO DD Health
Homes will be supported as the state continually assesses the DD Health Homes
to determine training needs. DD Health Homes will participate in a variety of
centralized learning supports including but not limited to learning
collaboratives, webinars, training and technical assistance including peer-led
training and community resources.
(D) Department's Identified System. DD Health
Homes shall utilize the department's identified system approved by the Division
of DD. The department's identified system is a system for tracking information
the Division of DD deems critical to the management of the health of the
population being served through the DD Health Home, including dates of
delivered and needed services, laboratory values needed to track chronic
conditions, and other measures of health status. The department's identified
system shall be used for-
1.
Tracking;
2. Risk
stratification;
3. Analysis of
population health status and individual needs; and
4. Reporting as specified by the Division of
DD.
(E) Data Reporting.
DD Health Homes shall be required to submit the following reports to the
Division of DD as specified:
1. Monthly
updates identifying the DD Health Home's staffing patterns, enrollment status,
hospital follow-ups, and notifications provided to primary healthcare
providers; and
2. Other reports as
specified by the Division of DD.
(4) Patient Eligibility and Enrollment. This
section describes eligibility and enrollment requirements for DD Health Home.
(A) Eligibility. Individuals eligible for
Division of DD services shall meet the following criteria to be eligible for
services from a designated DD Health Home:
1.
Have a chronic condition of intellectual and/or developmental disability;
and
2. Have or be at risk of
developing one (1) of the following conditions:
A. Diabetes;
B. Asthma;
C. Cardiovascular disease (CVD) or
hypertension;
D. Chronic
obstructive pulmonary disease (COPD);
E. Overweight (body mass index
(BMI)>25);
F.
Dementia;
G. Dependent on a
ventilator;
H. One (1) of the Fatal
Five Plus conditions or one (1) or more chronic conditions that could lead to
one (1) of the following Fatal Five Plus conditions:
(I) Pulmonary aspiration;
(II) Bowel obstruction;
(III) Gastroesophageal reflux disease
(GERD);
(IV) Seizures;
(V) Sepsis;
(VI) Dehydration;
I. Tobacco use;
J. Diagnosis of Autism Spectrum Disorder;
or
K. Healthcare level of 3 or
greater as identified by the Health Risk Screening Tool.
(B) Enrollment Requirements.
Individuals eligible for DD Health Home services will be assigned to eligible
providers. Upon enrollment, individuals assigned to a DD Health Home will be
informed by the Department of Mental Health. The notice will describe
assignment of the individual to a DD Health Home, provide a brief description
of DD Health Home services, and describe the process for the individual to
change DD Health Home provider, and opt-out of receiving services from the
assigned DD Health Home provider.
(5) DD Health Home Provider Designation
Process.
(A) The Division of DD shall
establish procedures under which a Medicaid-enrolled provider attains
designation as a DD Health Home provider.
1.
The designation process shall be person-centered and serve the following
critical purposes-
A. To determine how well DD
Health Home providers fulfill their responsibilities to individuals enrolled in
a DD Health Home; and
B. To
determine systems changes and practices needed so that DD Health Home providers
will be more responsive to the individual's needs.
2. DD Health Home providers shall demonstrate
innovation and initiative in pursuing, as well as commitment toward, continuous
quality improvement in realizing best practices and outcomes associated with-
A. Health Home core functional components-
(I) Provide quality-driven, cost-effective,
culturally appropriate, and person- and family-centered Health Home
services;
(II) Coordinate access to
high quality health care services informed by evidence-based clinical practice
guidelines;
(III) Coordinate access
to preventive and health promotion services, including prevention of mental
illness and substance use disorders;
(IV) Coordinate and provide access to
behavioral health services, including mental health and substance
use;
(V) Coordinate access to
comprehensive care management, care coordination, and transitional care across
settings. Transitional care includes appropriate follow-up from inpatient to
other settings, such as participation in discharge planning and facilitating
transfer from a pediatric to an adult system of health care;
(VI) Coordinate access to chronic disease
management, including self-management support to individuals and their
families;
(VII) Coordinate access
to individual and family supports, including referral to community, social
support, and recovery services;
(VIII) Coordinate access to long-term care
supports and services;
(IX) Develop
a person-centered care plan for each individual that coordinates and integrates
all of his or her clinical and non-clinical healthcare-related needs and
services;
(X) Demonstrate a
capacity to use health information technology to link services, facilitate
communication among team members and between the health team and individual and
family caregivers, and provide feedback to practices, as feasible and
appropriate; and
(XI) Establish a
continuous quality improvement program, and collect and report on data that
permits an evaluation of increased coordination of care and chronic disease
management on individual-level clinical outcomes, experience of care outcomes,
and quality of care outcomes at the population level; and
B. Service delivery system principles-
(I) Demonstrate clinical competency for
serving the complex needs of health home enrollees using evidence-based
protocols;
(II) Demonstrate the
ability for effectively coordinating the full range of medical, behavioral
health, long-term services and supports, and social services for medically
complex individuals with chronic conditions;
(III) Provide Health Home services that
operate under a "whole-person" approach to care using a comprehensive needs
assessment and an integrated person-centered care planning process to
coordinate care;
(IV) Have conflict
of interest safeguards in place to assure enrollee rights and protections are
not violated, and that services are coordinated in accordance with enrollee
needs expressed in the person-centered care plan;
(V) Provide access to timely health care
twenty-four (24) hours a day, seven (7) days a week to address any immediate
care needs of their Health Home enrollees;
(VI) Have in place operational protocol, as
well as communication procedures to assure care coordination across all
elements of the healthcare system (hospitals, specialty providers, social
service providers, other community based settings, etc.);
(VII) Have protocols for ensuring safe care
transitions, including established agreements and relationships with hospitals
and other community-based settings;
(VIII) Establish a continuous quality
improvement program that includes a process for collection and reporting of
Health Home data for quality monitoring and program performance; permits
evaluation of increased coordination and chronic disease management on
individual-level clinical outcomes, experience of care outcomes, and quality of
care outcomes at the population level;
(IX) Use data for population health
management, tracking tests, referrals and follow-up, and medication
management;
(X) Use health
information technology to link services and facilitate communication among
interdisciplinary team members and other providers to coordinate care and
improve service delivery across the care continuum.
3. Upon initial application and on
a biennial basis thereafter, all DD Health Home providers shall seek DD Health
Home designation under this section except those providers appropriately
accredited by nationally recognized accrediting bodies for DD Health Homes
approved by Division of DD shall not be required to seek designation. The
division director shall issue a DD Health Home designation to providers
successfully completing the process and requirements of this section.
(B) The Division of DD recognizes
and deems as designated a provider that has attained full accreditation under
standards for DD Health Home from a nationally recognized accrediting body. The
deemed provider must-
1. Submit to the
Division of DD a copy of the most recent accreditation survey report and
verification of the accreditation time period and dates within thirty (30)
calendar days of receipt from the accrediting body;
2. Notify the Division of DD when
accreditation surveys are scheduled or when the accrediting body makes
complaint investigation visits;
3.
Notify the Division of DD of any changes in accreditation status during the
time period of accreditation and resurvey;
4. Identify the Division of DD as a primary
stakeholder for contact by the accrediting body during survey and resurvey
data-gathering processes; and
5.
The Division of DD may conduct a scheduled or unscheduled survey of an
accredited DD Health Home provider at any time to monitor ongoing compliance
with the standards and requirements. If any survey finds conditions that are
not in compliance with applicable standards, the Division of DD may require
corrective action steps and may change the provider's designation status
consistent with procedures set out in this rule.
(C) Participation in Designation.
Participation may entail responding to surveys and requests for interviews with
DD Health Home staff and individuals served. Providers shall provide all
requested information as directed by the Division of DD. A provider must engage
in the designation process in good faith. The provider must provide information
and documentation that is accurate and complete. Failure to participate in good
faith, including falsification or fabrication of any information used to
determine compliance with requirements, may be grounds to deny issuance of or
to revoke designation.
1. The Division of DD
shall conduct a comprehensive survey at an organization for the purpose of
determining compliance with DD Health Home standards, standards of care,
program/service rules, and other requirements, except as stipulated in
paragraph (5)(A)3.
A. The Division of DD shall
provide advance notice and scheduling of routine, planned surveys.
B. The Division of DD shall notify the
applicant regarding survey date(s), procedures, and a copy of any survey
instrument that may be used. Survey procedures will include but are not limited
to interviews with provider staff, individuals being served, and other
interested parties; review of provider administrative records necessary to
verify compliance with requirements; and review of personnel records and
service documentation.
C. The
applicant agrees, by act of submitting a DD Health Home application, to allow
and assist Division of DD representatives in fully and freely conducting these
survey procedures, initially and ongoing, and to provide Division of DD
representatives reasonable and immediate access to premises, individuals, and
requested information.
D. The
surveyor(s) shall hold entrance and exit conferences with the organization to
discuss survey arrangements and survey findings, respectively. If there are any
deficiencies found during the survey, the provider will be required to submit a
plan of correction before designation can be approved.
E. If a plan of correction is not required,
the Division of DD shall issue DD Health Home designation to the provider's
director within thirty (30) calendar days after the exit conference, indicating
the DD Health Home provider can provide Health Home services.
F. Division of DD will identify and set
timelines for issues/enhancements to be addressed with the DD Health Home
provider. At the discretion of the Division of DD, a follow-up review will be
completed once issues have been addressed. If issues/enhancements have been
satisfactorily addressed, Division of DD will issue DD Health Home designation
to the provider.
(I) The report shall note all
deficiencies identified during the survey.
(II) The Division of DD shall send a notice
of deficiency and the report.
(III)
The DD Health Home provider shall make the report available to their staff and
to the public upon request.
(IV)
Within thirty (30) calendar days of the date that a notice of deficiency and
the report is presented to the DD Health Home provider, the provider shall
submit to the Division of DD a plan of correction. The plan must address each
deficiency, specifying the method of correction and the date the correction
shall be completed. The provider will work with the Division of DD to develop a
plan of correction. No correction date will exceed ninety (90) calendar
days.
(V) Within fifteen (15)
calendar days after receiving the plan of correction, the Division of DD shall
notify the DD Health Home provider of its decision to approve or require
revisions of the proposed plan.
(VI) The Division of DD will assure that the
plan of correction has been implemented and deficiencies corrected. Division of
DD shall determine if it is necessary to make a return visit to the DD Health
Home provider based on the criteria of the plan of correction.
(VII) In the event that the provider has not
submitted a plan of correction acceptable to Division of DD within forty-five
(45) calendar days of the original date that written notice of deficiencies was
presented by certified mail to the DD Health Home provider, it shall be subject
to expiration or denial of designation.
G. The Division of DD may grant designation
on a temporary, initial, conditional, deemed, or compliance status. The
Division of DD will notify the Division of DD Director of any change in the
status of a provider.
(I) Temporary status may
be granted to a DD Health Home provider if the designation process has not been
completed prior to the expiration of an existing designation and the applicant
is not at fault for failure or delay in completing the designation
process.
(II) Initial status for a
period of not exceeding one (1) year may be granted to a new provider based on
a designation review which finds the program in compliance with requirements
related to policy and procedure, facility, trainings and personnel to begin
providing services. The initial designation will be awarded for one (1) year
and a follow-up visit will occur prior to the initial designation expiration
date to ensure the DD Health Home provider is demonstrating continued
improvement and functionality.
(a) In the
Division of DD's initial determination and granting of initial designation, the
provider shall not be expected to fully comply with those standards which
reflect ongoing program activities.
(b) The Division of DD shall conduct a
comprehensive survey of the initially designated provider and shall make
further determination of the provider's designation status no later than the
expiration date of the initial designation.
(III) Conditional status may be granted to a
provider following a survey by the Division of DD that determines that there
are pervasive and/or significant deficiencies with standards that may affect
quality of care to individuals and there is reasonable expectation that the
provider can achieve compliance within a stipulated time period. The Division
of DD may consider patterns and trends of performance identified during the
survey.
(a) The period of conditional status
shall not exceed one hundred eighty (180) calendar days. The Division of DD may
directly monitor progress, may require the provider to submit progress reports,
or both.
(IV) The
Division of DD shall conduct a further survey within the one hundred eighty-
(180-) day period and make a further determination of the provider's compliance
with standards.
(V) Designation
status may be awarded to a provider for a period of two (2) years following a
survey by the Division of DD that determines the provider meets all standards
relating to quality of care and the safety, health, rights, and welfare of
individuals served.
H. If
deficiencies are cited during a survey, any and all such deficiencies must be
corrected in accordance with the plan of correction prior to the Division of DD
awarding designation status.
I. The
Division of DD may investigate any complaint regarding the operation of a
designated or deemed provider. If conditions are found that are not in
compliance with applicable requirements, the Division of DD may, at its sole
discretion for deemed providers, notify the accrediting body of any
concerns.
J. The Division of DD may
conduct a scheduled or unscheduled survey of a provider at any time to monitor
ongoing compliance with the standards and requirements. If any survey finds
conditions that are not in compliance with applicable standards, the Division
of DD may require corrective action steps and may change the provider's
designation status consistent with procedures set out in this rule.
K. The Division of DD may deny issuance of
and may revoke designation based on a determination that includes but is not
limited to-
(I) The nature of the deficiencies
results in substantial probability of or actual jeopardy to individuals being
served;
(II) Serious or repeated
incidents of abuse or neglect of individuals being served or violations of
rights have occurred;
(III)
Fraudulent fiscal practices have transpired or significant and repeated errors
in billings to the Division of DD have occurred;
(IV) Failure to participate in the
designation process in good faith, including falsification or fabrication of
any information used to determine compliance with requirements;
(V) The nature and extent of deficiencies
results in the failure to conform to the standards of the program being
offered; or
(VI) Compliance with
standards has not been attained by an organization upon expiration of
conditional designation.
L. An organization which has had designation
denied or revoked may meet with the Division of DD Director or designee to
appeal the decision to revoke designation.
(I)
The provider must notify the department's division director or designee in
writing within ten (10) business days of the date on the termination letter.
The appeal shall include the following-
(a)
The name of the provider;
(b) The
name and contact information of the person requesting the appeal;
(c) The reasons for appealing the decision;
and
(d) Any documentation that
supports the provider's position.
(II) The meeting shall take place within
seven (7) business days from the date of the request.
(III) Within seven (7) business days of the
meeting, the division director or designee shall make a final determination as
to whether the decision remains in effect. The provider shall be notified of
this decision by regular and certified mail.
(IV) The decision of the division director or
designee shall be the final decision of the department.
M. A designation is valid only as long as the
provider meets standards of care and other requirements.
N. The provider shall maintain the
designation issued by the Division of DD in a readily available
location.
O. Within seven (7)
business days of the time a designated provider organization is discontinued,
moved to a new location, or has a change in accreditation status, the provider
shall provide written notice to the Division of DD of any such
change.
P. The Division of DD shall
designate only the provider(s) named in the application.
Q. The provider(s) may not transfer
designation without the written approval of the department.
R. Within seven (7) calendar days of the
effective date that a designated provider is sold or undergoes a change of
ownership, the provider shall submit a written notice to the division of any
such change. A change in ownership is considered to have occurred under the
following circumstances:
(I) A new
corporation, partnership, limited partnership, limited liability company, or
other entity assumes ownership of the operation;
(II) An individual incorporates or forms a
partnership;
(III) With respect to
a designated provider that is a general partnership, a change occurs in the
majority interest of the partners;
(IV) With respect to a designated provider
that is a limited partnership, a change occurs in the majority interest of the
general or limited partners;
(V)
With respect to a designated provider that is a corporation, a change occurs in
the persons who own, hold, or have the power to vote the majority of any class
of stock issued by the corporation.
(VI) A designated provider's change of
Federal Employer Identification Number (FEIN).
S. The organization must comply with other
applicable requirements as set forth in
9 CSR
10-5.220 Privacy Rule of Health Insurance Portability
and Accountability Act of 1996 (HIPAA).
(6)
Demonstrated Evidence of DD Health Home Transformation.
(A) Providers are required to demonstrate
evidence of transformation to the DD Health Home model on an ongoing basis
using measures and standards established by the Division of DD and communicated
to the providers. Transformation to the DD Health Home service delivery model
is exhibited when a provider-
1. Demonstrates
development of fundamental DD Health Home functionality initially upon
enrollment, one (1) year prior to the expiration of the initial designation,
and biennially thereafter, based on an assessment process determined by the
Division of DD. Additional reviews may be indicated on a case-by-case basis.
Providers must demonstrate continued improvement and functionality for as long
as they maintain their DD Health Home designation; and
2. Demonstrates progress toward established
goals and objectives related to the clinical indicators as determined by
Division of DD.
(B)
Notification of Staffing Changes. Providers are required to notify the Division
of DD within seven (7) business days of staff changes in the DD Health Home
Director, Physician Consultant (APRN as substitute), Nurse Care Manager(s), and
DD Health Home Facilitator.
(C)
Providers shall work cooperatively with the Division of DD to support approved
training, technology, and administrative services required for ongoing
implementation and support of the DD Health Homes.
(7) Health Home Payment Components. This
section describes the payment process for Developmental Disabilities Health
Homes.
(A) General.
1. All payments to a DD Health Home are
contingent on the program meeting the DD Health Home requirements set forth in
their Health Home applications, as determined by the state of Missouri. Failure
to meet such requirements is grounds for revocation of Health Home status and
for termination of payments.
2.
Reimbursement for DD Health Home services will be in addition to a provider's
existing reimbursement for services and procedures and will not change existing
reimbursement for services and procedures that are not part of the DD Health
Home.
3. The Division of DD
reserves the right to make changes to the payment methodology.
(B) Types of Payments.
1. Clinical Care Management per Member per
Month (PMPM) payment. Missouri will pay DD Health Homes the cost of staff
primarily responsible for delivery of services not covered by other
reimbursement (Health Home Director, Physician Consultant (APRN as substitute),
Nurse Care Manager, Specialized Healthcare Consultant and DD Health Home
Facilitator), whose duties are not otherwise reimbursable by MO HealthNet. In
addition, the DD Health Home PMPM will include Health Home specific training,
technical assistance, administration, and data analytics. Staff costs are based
on the Bureau of Labor Statistics data. All DD Health Home providers will
receive the same PMPM rate. The PMPM method will be reviewed periodically to
determine the rate is economically efficient and consistent with quality of
care.
(C) Minimum
Criteria for Payment.
1. The individual is
identified as meeting the DD Health Home eligibility criteria on the state-run
DD Health Home department's identified system.
2. The individual is enrolled with a
designated billing DD Health Home provider, and is enrolled in only one (1)
Health Home at a time, regardless of type.
3. The minimum DD Health Home service
required to merit payment of the PMPM is that the individual has received care
management monitoring for treatment gaps that was documented or another DD
Health Home service was provided that was documented.
4. The DD Health Home will report that the
minimal service required for the PMPM rate payment occurred on a monthly DD
Health Home attestation report.
(D) Except as otherwise noted in the plan,
state-developed PMPM rates are the same for both governmental and private
providers of DD Health Home services.
(8) Policies and Procedures. The organization
shall maintain a policy and procedure manual that accurately describes and
guides the operation of its services and promotes compliance with applicable
regulations. The policy and procedure manual shall be readily available to
staff and the public upon request and shall include but is not limited to-
(A) The DD Health Home provider will develop
policies and procedures in accordance with 9 CSR 10-5 to include-
1.
9 CSR
10-5.190 Background Screening Requirements;
2.
9 CSR
10-5.200 Report of Complaints of Abuse, Neglect and
Misuse of Funds/Property;
3.
9 CSR
10-5.206 Report of Events; and
4.
9 CSR
10-5.220 Privacy Rule of the Health Insurance
Portability and Accountability Act (HIPAA) and 42 CFR; and
(B) The DD Health Home provider will develop
policies and procedures to address the following:
1. Opt-out process for individuals that
otherwise qualify for DD Health Home services;
2. Transfer and discharge processes for DD
Health Home individuals;
3. Primary
care physician referrals;
4.
Primary care physician or other specialty care coordination;
5. Twenty-four (24) hour coverage in
accordance with paragraph (2)(A)3. of this rule;
6. Prescription monitoring;
7. Health Risk Screening Tool and routine
monitoring;
8. Quality
assurance/quality improvement process as related to DD Health Home;
9. Guidelines to follow across risk levels or
health conditions;
10. Follow-up
care after discharge related to transitional care;
11. Training requirements for DD Health Home
staff;
12. DD Health Home data
reporting;
13. Composition of DD
Health Home team;
14. Notification
of DD Health Home staffing changes;
15. Utilization of the department's
identified system;
16. Complaints
and grievances; and
17. Attestation
and documentation.
(9) Incorporation by Reference. This rule
incorporates by reference the following:
(A)
The DD Health Home Provider Operations Manual is incorporated
by reference and made a part of this rule as published May 15, 2024, by the
Department of Mental Health, Division of Developmental Disabilities, at its
website at https://dmh.mo.gov/dev-disabilities/health-home.
This rule does not incorporate any subsequent amendments or additions to this
publication.
(10)
Electronic Medical Records. DD Health Home providers are required to utilize
and maintain electronic medical records of all individuals served. Electronic
medical records systems must comply with state and federal
regulations.
Notes
State regulations are updated quarterly; we currently have two versions available. Below is a comparison between our most recent version and the prior quarterly release. More comparison features will be added as we have more versions to compare.
No prior version found.